RESEARCH ARTICLE
Title:
Comparing online and face-to-face student counselling: what therapeutic goals are identified and what are the implications for educational providers?
Authors:
Terry Hanley, Senior Lecturer in Counselling Psychology, University of Manchester
Zehra Ersahin, Counselling Psychologist in Doctoral Training, University of Manchester
Aaron Sefi, Research and Outcomes Lead for Xenzone
Judith Hebron, Research Fellow, University of Manchester
Declaration:
We confirm that this manuscript is an original piece of work that has not been submitted nor published anywhere else.
All authors have read and approved the paper and have met the required criteria for authorship.
Suggested Running Head:
Comparing online and face-to-face student counselling
Correspondence:
Terry Hanley
Email:
Post: Rm.A6.15. Ellen Wilkinson Building, University of Manchester, Oxford Road, Manchester. M13 9PL
Telephone: 0161 2758815
Word Count: 5720 (inc. abstract and references)
Title
Comparing online and face-to-face student counselling: what therapeutic goals are identified and what are the implications for professionals working in educational settings?
Abstract
Online counselling is increasingly being used as an alternative to face-to-face student counselling. Using an exploratory mixed methods design, this project investigates the practice by examining the types of therapeutic goals that 11 to 25 year olds identify online in routine practice. These goals are then compared to goals identified in equivalent school and community-based counselling services. 1,137 online goals (expressed by 504 young people) and 221 face-to-face goals (expressed by 220 young people) were analysed for key themes using grounded theory techniques. This analysis identified three core categories (1) Intrapersonal Goals, (2) Interpersonal Goals, and (3) Intrapersonal Goals directly related to others. Further statistical analysis of these themes indicated that online and face-to-face services appear to be being used in different ways by students. These differences are discussed alongside the implications for professionals working in educational settings.
Key words: Adolescents, Online counselling; School-based Counselling; Youth counselling; Goal-Oriented Therapy; Help-Seeking Behaviours
Background
This project was completed in conjunction with KOOTH, a counselling and support service for 11-25 year olds in the United Kingdom (UK). It has been widely involved in the development of services that are easy to access and youth friendly. As such, it provides anonymous online counselling using a single point of access via a website (www.kooth.com) and face-to-face counselling within secondary schools and community settings. All services are funded by external partners, such as Local Authorities and the National Health Service’s Clinical Commissioning Groups, and are free at the point of delivery. The counselling offered by the KOOTH service is pluralistic (Cooper & McLeod, 2011) and explicitly focused upon the goals that the individuals accessing therapy identify alongside their counsellors. Below we outline how the literature related to the context of the service and this goal oriented approach feed into the aims of this study.
Developing accessible counselling for students
Young people and young adults are highlighted as a group that are at risk of psychological distress (e.g. Coleman & Brooks, 2009). As education providers commonly have substantial contact with individuals during this life stage, they are increasingly recognised as having the potential to become hubs for offering whole school and targeted social and emotional support (Department of Health, 2015). Such interventions have been linked to improvements in students’ social and emotional competence, academic attainment and ability to engage with learning, improvements in behaviour, and the reduction of mental health problems more generally (Department of Education, 2015; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). As a consequence, educational providers can be seen to be routinely funding mental health services through their own budgets (e.g. Hanley, Jenkins, Barlow, Humphrey, & Wigelsworth, 2013), and the development of appropriate and accessible targeted services, such as counselling, has become a major consideration for schools (e.g. Harris, 2013).
When seeking psychological support, young people and young adults appear to look increasingly towards the Internet (Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005). In response to this growing need, online counselling services have begun to develop with the hope of further increasing the accessibility of therapeutic services (Pattison, Hanley, Pykhtina, & Ersahin, 2015). Notably, such services have emerged throughout the world – for example in Africa: Pattison, Hanley and Sefi (2012); Australia: Glasheen and Campbell (2009); and Europe: Vossler and Hanley (2010). These services have been created to respond to national contexts and have been used in conjunction with, and as an alternative to, traditional face-to-face delivery (e.g. school-based counselling services). Interestingly, where counselling has been accessed by young people outside traditional healthcare settings (e.g. within school-based counselling) it is notable that the severity of presenting issues does not appear to vary (Cooper, 2013). There is even some indication that online presentations may be more complex than some face-to-face settings (Sefi & Hanley, 2012).
Benefits are reported for both those accessing and providing online counselling services. Young users report that they find the online environment safe and feel less exposed, confronted and stigmatised (e.g. Hanley, 2012; King, Bambling, Lloyd, et al., 2006). Therefore, the anonymity of online counselling helps to ease the discomfort of making what can be perceived as embarrassing disclosures. Further, the increased ability and freedom to access such services is also suggested to enhance client autonomy in the therapeutic relationship, thus empowering the young person in the therapeutic dyad (Gibson & Cartwright, 2013; Hanley, 2012). Counsellors express similar positive sentiments. Specifically, they report that therapeutic relationships can be more convenient and feel safer when working online with young people (e.g. Bambling, King, Reid, & Wegner, 2008; Dowling & Rickwood, 2016; Glasheen, Campbell, & Shochet, 2013).
In contrast to the benefits, challenges related to online practice with this group are also reported within the literature. For instance, practical concerns are noted around the infrastructure needed for such practice (Callahan & Inckle, 2012; Hanley, 2006) and the delivery of effective therapeutic interventions are also raised. In relation to the latter, King, Bambling, Reid, and Thomas (2006) and King, Bambling, Lloyd, et al. (2006) report user concerns over the counsellor's ability to grasp their feelings (and vice versa), the limited exchange time in text format within the time constraints, and the loss of immediacy in online practices. Therefore, although online counselling for young people is still an emerging field, it is an arena that is growing at pace and in need of further consideration.
Goal Oriented Therapy
Therapy that is oriented towards the goals of young people is increasingly being advocated by psychologists (e.g. Hanley, Williams, & Sefi, 2013). Therapeutic goals have been described as the “internal representations of desired states” (Austin & Vancouver, 1996, p. 338). Therapeutic approaches that advocate the articulation of goals from clients often base this approach within existential philosophies that place emphasis on the purposeful, and future-oriented nature of the human (e.g. Cooper, 2015; Hanley, Sefi, & Ersahin, 2016). This position commonly aligns itself to the holistic stance of humanistic psychology (e.g. Bugental, 1964) and views clients as active agents within the therapeutic process (Bohart, 2000; also see Gibson & Cartwright, 2013 for a discussion of agency in therapy with young people). Furthermore, within psychological literature, the focus upon goals in therapy has particularly gathered momentum in the concept of the therapeutic alliance (as first described by Arbor and Bordin (1979)). Within this conceptualization, goals are viewed alongside the therapeutic bond and tasks as key common factors of the therapeutic relationship. The alliance has received much attention in the therapeutic research literature and been identified as a major contributor to successful therapeutic outcomes for both adult (Horvath, Del Re, Flückiger, & Symonds, 2011) and adolescent populations (Shirk, Karver, & Brown, 2011).
The goals with which individuals approach therapy are incredibly varied. A variety of taxonomies have been developed to categorize these. For instance, the Bern inventory (Grosse & Grawe, 2002) summarizes 1,031 goals articulated by 298 out-patients at a university clinic into five different categories: (1) coping with specific problems and symptoms, (2) interpersonal goals, (3) well-being and functioning, (4) existential issues, and (5) personal growth. Similarly, Rupani et al. (2013) explored 199 goals expressed by 73 young people who had accessed school-based counselling. These findings revealed that the goals fell into four major domains: (1) Emotional Goals, (2) Interpersonal Goals, (3) Goals targeting specific issues, and (4) Personal Growth goals. As is evident within these two classification systems, taxonomies vary in their degrees of divergence and convergence.
Goal-oriented therapy refers to therapeutic practice in which interventions are focused around the specific goals that have been articulated by the client (or clients). As with the therapeutic alliance, the consensus between the goal of the therapist and client is an element of the therapeutic relationship that meta-analyses report to have a positive effect upon the therapeutic outcome (Tryon & Winograd, 2011). With such sentiments in mind, therapeutic approaches, such as Cooper and McLeod’s pluralistic framework for counselling and psychotherapy (2011), have been specifically devised to harness the potential positive components of such a process. As well as being utilized in adult populations, the pluralistic framework has also been suggested for therapeutic work with young people (Hanley, Williams, et al., 2013). Within this framework, goal articulation is viewed as an ethically-minded position supporting the client to be actively involved in helping to orchestrate the therapeutic process (Hanley et al., 2016).
Rationale
As online therapeutic work becomes more commonplace for student populations, further examination of the type of work being undertaken is much needed. This project therefore provides a significant exploration of the field by examining collaboratively developed therapy goals that are expressed in counselling sessions. Such investigation will help professionals to further understand not only the reasons why young people seek support online, but also to gain a sense of the impact of new technologies upon the types of goals that individuals seek to address in therapy. Identifying such factors will prove helpful to service providers, such as in educational settings, when considering whether to invest in such provision. With this in mind, the following research questions were formulated for the study:
1. What type of goals do young people identify as working towards during online and face-to-face therapy?
2. How do the goals that young people articulate online and face-to-face compare?
3. Based upon the goals identified, how might online counselling services impact upon professionals working in educational settings?
Methodology
This study utilized an exploratory mixed methods research design (Creswell, Plano Clark, Gutmann, & Hanson, 2003). Initially a qualitative approach (Grounded Theory) was taken to make sense of the wide variety of goals that had been articulated during the counselling sessions. Following this, statistical analysis (inferential and descriptive) was used to compare the prevalence of the different types of goals that were reported in online and face-to-face settings.
Data Collection: Procedure, participants, and ethical considerations
The project involved collating the therapy goals of 11 to 25 year olds who used the KOOTH counselling services. All the data considered here was routinely collected by the therapy services. Goals were formed collaboratively with counsellors at the outset of counselling (or during regular review periods) using the organisation’s Counselling Goal System (CoGS). A version of the CoGS was embedded within the online system and a paper version used with face-to-face clients (see Appendix 1 for a blank version of the form used in face-to-face work). This encourages clients to briefly articulate goals for counselling (e.g. “To explore why I feel people don’t like me”) and enables achievement of goals to be reviewed quantitatively (regularly asking clients to rate whether they have been met since their last meeting). The counsellors working for the service were originally trained in a range of therapeutic approaches. All had received training in the process of supporting young people to articulate their goals for counselling and those working online had also received training to work in this medium.
The counselling was either delivered online (using the online access point www.kooth.com) or face-to-face within a school or community setting. Although confirmation of the service user’s location is required for the online service, no personally identifiable material is required for an individual to use it. This is in contrast to the face-to-face service where people are likely to have been referred by a member of the school staff. No record of the referrer was available at the time of analysis.
Within the online sample, 1,137 goals were collated from 504 young people during the time period December 2013 – July 2014 (74% identified themselves as female, with the mean age being 16.5 (median 16, SD 2.76). During the same period, 221 goals were collated from 220 young people accessing face-to-face therapy (66% were from school based provision and 34% from services based in the local community; 70% were female; and the mean age was 14 [median 14, SD 2.00]). The demographics of the service users here generally reflect the demographic make-up of the services more generally.
The research was approved by the University Research Ethics Committee associated with the lead authors place of work. It adhered to the Code of Human Research Ethics developed by British Psychological Society (2010) as well as the ethical guidelines of the host organisation (Bond, 2004).
Data Analysis
Techniques from the grounded theory approach were used to analyse the goals that had been articulated by the young people for key themes (Charmaz, 2000). The inductive nature of the analysis meant that previous conceptualisations of goal taxonomies were not considered during the initial analysis stage. This naïve stance was adopted so that the analysis would not be greatly influenced by the thinking of others and thus the analysis would be open to new themes (e.g. Rennie & Fergus, 2006)
Common protocols associated with grounded theory were utilized to develop a hierarchy related to the data in question (Strauss & Corbin, 1998). The goals that the young people reported (N=1,358 were divided into meaning units (MUs: see Rennie, Phillips, & Quartaro, 1988) and coded into representing categories by two members of the research team. During this process a number of the goals were divided up so as to account for their multifaceted nature (MUs ultimately totalling 1,469). Once agreement was reached on the categorisation of these lower order codes, exploration of the commonalities led to the creation of higher order categories. This constant comparison across categories enabled the authors to reflect upon the internal consistency of the developing model (Maykut & Morehouse, 1994). A third team member was utilised as a means of checking the coherence of the analysis and to mediate any disagreement between the core coders.